Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 101: A patient presents with a normal anterior chamber and hazy cornea in one eye, and a shallow anterior chamber and miotic pupil in the fellow eye. What is the most likely diagnosis?

A. Endophthalmitis
B. Acute congestive glaucoma
C. Chronic simple glaucoma
D. Acute anterior uveitis (Correct Answer)

Explanation: **Explanation:** The correct answer is **Acute Anterior Uveitis**. The clinical presentation hinges on the concept of **iris bombé** and **seclusio pupillae**. In severe or recurrent uveitis, posterior synechiae (adhesions between the iris and lens) can occur. If these adhesions involve 360° of the pupil (seclusio pupillae), aqueous humor cannot flow from the posterior to the anterior chamber. This causes the peripheral iris to bulge forward (**iris bombé**), resulting in a **shallow anterior chamber** in that eye. The "hazy cornea" in the fellow eye is often due to inflammatory keratic precipitates or corneal edema. **Analysis of Incorrect Options:** * **Acute Congestive Glaucoma:** While this presents with a shallow anterior chamber and hazy cornea, it typically features a **mid-dilated, vertically oval pupil**, not a miotic one. * **Chronic Simple Glaucoma (POAG):** This is a silent, progressive disease characterized by a **normal/deep anterior chamber** and a normal-looking cornea. It does not present with acute haziness or pupillary changes. * **Endophthalmitis:** This is a devastating intraocular inflammation (usually post-surgical) presenting with severe pain, loss of vision, and hypopyon. While the cornea may be hazy, the specific combination of a shallow AC and miotic pupil in the fellow eye points more specifically to the structural sequelae of uveitis. **NEET-PG High-Yield Pearls:** * **Uveitis Pupil:** Characteristically **miotic** due to ciliary spasm and irritation. * **Glaucoma Pupil:** Characteristically **mid-dilated** due to sphincter ischemia. * **Iris Bombé:** Leads to secondary angle-closure glaucoma; the definitive treatment is **Laser Peripheral Iridotomy (LPI)**. * **Festooned Pupil:** An irregular pupil shape seen in uveitis after using mydriatics, caused by patchy posterior synechiae.

Question 102: Which of the following is not an antiglaucoma drug?

A. Brimonidine
B. Prednisolone (Correct Answer)
C. Dorzolamide
D. Timolol

Explanation: **Explanation:** The correct answer is **Prednisolone**. Prednisolone is a potent **corticosteroid**, not an antiglaucoma medication. In fact, corticosteroids are notorious for being **glaucomatogenic**. They decrease the facility of aqueous outflow by causing structural changes in the trabecular meshwork (e.g., accumulation of glycosaminoglycans), which leads to an increase in Intraocular Pressure (IOP), a condition known as **Steroid-Induced Glaucoma**. **Analysis of other options:** * **Brimonidine:** A highly selective **Alpha-2 (α2) Adrenergic Agonist**. It works by a dual mechanism: decreasing aqueous humor production and increasing uveoscleral outflow. * **Dorzolamide:** A topical **Carbonic Anhydrase Inhibitor (CAI)**. It reduces IOP by inhibiting the enzyme carbonic anhydrase in the ciliary processes, thereby decreasing the secretion of aqueous humor. * **Timolol:** A non-selective **Beta-Blocker**. It is often the first-line treatment for glaucoma and works by reducing aqueous humor production from the ciliary body. **High-Yield Clinical Pearls for NEET-PG:** 1. **Steroid Responders:** Approximately 5–10% of the general population (and nearly all patients with POAG) show a significant rise in IOP after 4–6 weeks of topical steroid use. 2. **Drug of Choice (DOC):** Prostaglandin analogues (e.g., Latanoprost) are currently the DOC for Primary Open Angle Glaucoma (POAG) due to their once-daily dosing and superior IOP-lowering efficacy. 3. **Side Effect Note:** Brimonidine is known to cause **follicular conjunctivitis** in about 30% of patients.

Question 103: Which of the following medications should not be used in a patient with acute angle-closure glaucoma associated with uveitis?

A. Timolol
B. Pilocarpine (Correct Answer)
C. Atropine
D. Acetazolamide

Explanation: **Explanation:** In the management of glaucoma, the underlying etiology dictates the treatment. While **Pilocarpine** is a first-line miotic agent for primary acute angle-closure glaucoma (by pulling the iris away from the angle), it is **strictly contraindicated** in glaucoma secondary to **uveitis**. **Why Pilocarpine is contraindicated:** 1. **Blood-Aqueous Barrier:** Pilocarpine is a parasympathomimetic that increases inflammation by further breaking down the blood-aqueous barrier, worsening the uveitis. 2. **Posterior Synechiae:** Miosis (pupillary constriction) increases the surface area of contact between the iris and the lens, promoting the formation of posterior synechiae. This can lead to 360-degree synechiae (seclusio pupillae) and iris bombe, paradoxically worsening the angle closure. **Analysis of Incorrect Options:** * **Timolol (A):** A topical beta-blocker that reduces aqueous production. It is safe and commonly used in both primary and uveitic glaucoma. * **Atropine (C):** In uveitic glaucoma, cycloplegics like Atropine are actually indicated. They stabilize the blood-aqueous barrier, reduce pain by relieving ciliary spasm, and prevent synechiae by keeping the pupil dilated. * **Acetazolamide (D):** A systemic carbonic anhydrase inhibitor that rapidly lowers intraocular pressure by decreasing aqueous secretion. It is a standard emergency treatment for all types of acute pressure elevation. **NEET-PG High-Yield Pearls:** * **Drug of choice for Primary Acute Angle Closure:** Pilocarpine (after IOP is lowered). * **Drug of choice for Uveitic Glaucoma:** Topical steroids (to treat inflammation) and Cycloplegics (Atropine/Homatropine). * **Avoid in Uveitis:** Pilocarpine and Prostaglandin analogues (Latanoprost) as they are pro-inflammatory.

Question 104: A 63-year-old woman presents with a complaint of pain in her right eye. On examination, the pupil is dilated with a hazy cornea. What is the most likely diagnosis?

A. Scleritis
B. Anterior uveitis
C. Conjunctivitis
D. Acute angle closure glaucoma (Correct Answer)

Explanation: **Explanation:** The clinical presentation of **Acute Angle Closure Glaucoma (AACG)** is a classic medical emergency frequently tested in NEET-PG. The diagnosis is based on the triad of sudden ocular pain, a **hazy (edematous) cornea**, and a **vertically oval, semi-dilated, non-reactive pupil**. The haziness is caused by a rapid rise in intraocular pressure (IOP) leading to corneal edema, while the pupil becomes fixed and dilated due to ischemia of the iris sphincter muscle. **Why the other options are incorrect:** * **Scleritis:** Presents with severe, boring pain and deep-seated redness, but the cornea remains clear and the pupil is normal in size and reaction. * **Anterior Uveitis:** Characterized by a **constricted (miotic) pupil** due to ciliary spasm and a clear cornea (though keratic precipitates may be seen on slit-lamp). * **Conjunctivitis:** A painless condition (or mild grittiness) with discharge. The cornea is clear, and the pupil reacts normally to light. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Hypermetropia (small eyes), shallow anterior chamber, and increasing age. * **Symptoms:** Halos around lights (due to corneal edema) and systemic symptoms like nausea/vomiting (often misdiagnosed as an abdominal issue). * **Gold Standard Diagnosis:** Gonioscopy (to visualize the closed angle). * **Immediate Management:** IV Acetazolamide and topical pilocarpine (once IOP drops). * **Definitive Treatment:** Peripheral Iridotomy (PI) – usually performed in both eyes as the fellow eye is at high risk.

Question 105: Which topical drug can cause Heterochromia Iridis?

A. Timolol
B. Olopatadine
C. Latanoprost (Correct Answer)
D. Brimonidine

Explanation: **Explanation:** **Latanoprost** is a Prostaglandin Analogue (PGA) used as a first-line treatment for Open-Angle Glaucoma. It causes **Heterochromia Iridis** (specifically hyperpigmentation) by increasing the production of melanin within the stromal melanocytes of the iris. It is important to note that this occurs due to increased melanogenesis, not an increase in the number of melanocytes (no hyperplasia). This change is usually permanent and most noticeable in individuals with hazel or multicolored eyes. **Analysis of Incorrect Options:** * **Timolol (Option A):** A non-selective beta-blocker. Its primary side effects are systemic (bradycardia, bronchospasm) and local (stinging, dry eye), but it does not affect iris pigmentation. * **Olopatadine (Option B):** An antihistamine and mast cell stabilizer used for allergic conjunctivitis. It has no role in glaucoma management or iris color changes. * **Brimonidine (Option C):** An alpha-2 agonist. Common side effects include follicular conjunctivitis and lethargy (especially in children), but it does not cause heterochromia. **High-Yield Clinical Pearls for NEET-PG:** 1. **PGA Side Effects (Mnemonic: "3 L's"):** **L**ashes (Hypertrichosis/lengthening), **L**ids (Pigmentation of periorbital skin), and **L**iris (Heterochromia). 2. **Prostaglandin-Associated Periorbitopathy (PAP):** PGAs can cause deepening of the upper eyelid sulcus and fat atrophy. 3. **Contraindication:** PGAs should be avoided in **Uveitic Glaucoma** as they are pro-inflammatory and can exacerbate cystoid macular edema (CME).

Question 106: Glaukomflecken is a feature of which condition?

A. Acute narrow-angle glaucoma (Correct Answer)
B. Pseudoexfoliative glaucoma
C. Juvenile glaucoma
D. Phacolytic glaucoma

Explanation: **Explanation:** **Glaukomflecken** (also known as Vogt’s spots) are small, grayish-white, subepithelial opacities found in the anterior lens capsule. They represent **focal areas of lens epithelial necrosis** caused by a sudden, severe rise in intraocular pressure (IOP). 1. **Why Option A is Correct:** In **Acute Narrow-Angle Glaucoma**, the IOP rises rapidly and significantly (often >60 mmHg). This extreme pressure compromises the metabolic exchange between the aqueous humor and the lens epithelium, leading to localized cell death. These necrotic spots are pathognomonic of a *previous* attack of acute congestive glaucoma. 2. **Why Other Options are Incorrect:** * **Pseudoexfoliative Glaucoma:** Characterized by "dandruff-like" white deposits on the lens capsule and pupillary margin, not focal epithelial necrosis. * **Juvenile Glaucoma:** A form of primary open-angle glaucoma occurring in young individuals; it typically presents with a gradual rise in IOP, which does not cause Glaukomflecken. * **Phacolytic Glaucoma:** A lens-induced glaucoma where proteins leak from a hypermature cataract. While IOP is high, the primary feature is a heavy flare and macrophages in the anterior chamber, not these specific lens opacities. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Post-Acute Attack:** Glaukomflecken, iris atrophy (patchy), and a vertically oval, semi-dilated non-reacting pupil. * **Location:** Always located in the **anterior** subepithelial region of the lens. * **Significance:** Their presence is a "diagnostic footprint" indicating that the patient has suffered a severe acute angle-closure attack in the past, even if the current IOP is normal.

Question 107: A 30-year-old female who has been wearing contact lenses continuously for 2 months develops symptoms. Which of the following is the least likely cause of her symptoms?

A. Giant papillary conjunctivitis
B. Microbial keratitis
C. Increased sensitivity
D. Open-angle glaucoma (Correct Answer)

Explanation: **Explanation:** The core concept here is the relationship between **contact lens (CL) wear** and ocular surface complications. Continuous or extended wear of contact lenses significantly increases the risk of mechanical, immunological, and infectious pathologies of the cornea and conjunctiva. **Why Open-angle glaucoma (OAG) is the correct answer:** Open-angle glaucoma is a chronic, progressive optic neuropathy characterized by increased intraocular pressure (IOP) due to resistance in the trabecular meshwork. There is **no clinical or physiological evidence** linking the use of contact lenses to the development of open-angle glaucoma. While steroids used to treat CL-related complications can cause secondary glaucoma, the lens itself does not cause OAG. **Analysis of Incorrect Options:** * **A. Giant Papillary Conjunctivitis (GPC):** This is a common immune-mediated inflammatory response to the contact lens material or protein deposits on the lens surface. It presents with large papillae on the superior palpebral conjunctiva. * **B. Microbial Keratitis:** This is the most serious complication of CL wear, especially with overnight use. The lens acts as a vector for pathogens (like *Pseudomonas* or *Acanthamoeba*) and causes corneal hypoxia, which compromises the epithelial barrier. * **C. Increased Sensitivity:** Prolonged CL wear can lead to corneal hypersensitivity or, conversely, decreased corneal sensation (hypesthesia) due to chronic hypoxia and mechanical friction. **High-Yield Clinical Pearls for NEET-PG:** * **Acanthamoeba Keratitis:** Classically associated with contact lens users who use tap water for cleaning; presents with a characteristic **ring-shaped infiltrate**. * **Corneal Neovascularization:** A sign of chronic hypoxia in long-term CL users. * **Tight Lens Syndrome:** Occurs when a lens fits too snugly, leading to acute redness, pain, and corneal edema due to lack of tear exchange.

Question 108: Peripheral iridectomy is indicated in which of the following conditions?

A. Open angle glaucoma (Correct Answer)
B. Angle closure glaucoma
C. Malignant glaucoma
D. All of the above

Explanation: **Explanation:** **1. Why Open Angle Glaucoma (OAG) is the correct answer:** In the context of this specific question, **Peripheral Iridectomy (PI)** is indicated in Open Angle Glaucoma when it is performed as a prophylactic or preparatory step during a **Trabeculectomy** (filtering surgery). During trabeculectomy, a small piece of the peripheral iris is removed to prevent the iris root from being sucked into the new internal ostium, which would otherwise cause sudden blockage and surgical failure. **2. Why the other options are incorrect:** * **Angle Closure Glaucoma (ACG):** While a hole in the iris is the definitive treatment for ACG, the modern "Gold Standard" is **Laser Peripheral Iridotomy (LPI)**. Surgical Peripheral Iridectomy is now rarely performed and is reserved only for cases where laser treatment is impossible (e.g., hazy cornea or lack of patient cooperation). * **Malignant Glaucoma (Ciliary Block Glaucoma):** This is a posterior segment problem where aqueous is misdirected into the vitreous. The treatment involves cycloplegics, vitreous aspiration, or vitrectomy. A simple iridectomy does not resolve the underlying ciliary block. **High-Yield Clinical Pearls for NEET-PG:** * **Laser vs. Surgical:** Always remember: **LPI** is for Angle Closure; **Surgical PI** is a component of Trabeculectomy (OAG). * **Mechanism:** The primary goal of PI in ACG is to bypass **pupillary block** by equalizing pressure between the posterior and anterior chambers. * **Triple Procedure:** PI is also performed during a "Triple Procedure" (Cataract extraction + IOL + Trabeculectomy). * **YAG Laser:** The most common laser used for Iridotomy is the Nd:YAG laser.

Question 109: Which of the following is NOT a treatment for acute congestive glaucoma?

A. Sclerectomy
B. Trabeculectomy
C. Trabeculoplasty (Correct Answer)
D. All of the above

Explanation: In **Acute Congestive Glaucoma** (Acute Angle Closure), the primary pathology is a sudden, total mechanical obstruction of the drainage angle by the iris. The goal of treatment is to rapidly lower intraocular pressure (IOP) and physically open the angle. ### Why Trabeculoplasty is the Correct Answer **Trabeculoplasty** (specifically Argon Laser Trabeculoplasty or ALT) is used in **Open Angle Glaucoma**. It involves applying laser burns to the trabecular meshwork to increase outflow. In acute congestive glaucoma, the angle is physically closed (the iris is touching the cornea), making the trabecular meshwork **invisible and inaccessible** to the laser. Therefore, it is contraindicated and ineffective in an acute attack. ### Analysis of Other Options * **Sclerectomy:** This is a type of filtering surgery where a portion of the sclera is removed to create a new drainage channel. While not the first-line treatment, it is a surgical option for refractory cases. * **Trabeculectomy:** This is the "gold standard" filtering surgery. It is performed in acute glaucoma if medical management and peripheral iridotomy fail to control the IOP. ### NEET-PG High-Yield Pearls * **Immediate Management:** The first step is medical—**IV Mannitol** (osmotic diuretic) and **Acetazolamide** to rapidly lower IOP, followed by topical Pilocarpine (once IOP <40 mmHg) to pull the iris away from the angle. * **Definitive Treatment:** **Laser Peripheral Iridotomy (LPI)** is the treatment of choice for both the affected eye and the fellow (prophylactic) eye. * **The "Mid-Dilated Pupil":** A vertically oval, non-reactive, mid-dilated pupil is a classic clinical sign of an acute attack. * **Trabeculoplasty vs. Iridotomy:** Remember, *Trabeculoplasty* is for Open Angle; *Iridotomy* is for Closed Angle.

Question 110: Which of the following is NOT a feature of absolute angle closure glaucoma?

A. Painful blind eye
B. Bullous keratopathy
C. Atrophic iris
D. Phthisis (Correct Answer)

Explanation: ### **Explanation: Absolute Angle Closure Glaucoma** Absolute glaucoma is the final, end-stage stage of primary angle-closure glaucoma where the eye has **no light perception (NLP)**. It is characterized by a chronically high Intraocular Pressure (IOP) that leads to irreversible damage. **Why Option D (Phthisis) is the Correct Answer:** Phthisis bulbi refers to a shrunken, non-functional eye with **low intraocular pressure (hypotony)**, usually resulting from ciliary body failure. In contrast, absolute glaucoma is defined by a **stony hard eye** due to severely **elevated IOP**. While an absolute glaucomatous eye may eventually degenerate, phthisis is not a feature of the "absolute stage" itself; rather, it is a separate pathological end-point. **Analysis of Incorrect Options:** * **A. Painful blind eye:** This is the hallmark of absolute glaucoma. The extremely high IOP causes chronic congestion and nerve irritation, leading to severe ocular pain. * **B. Bullous keratopathy:** Persistent high IOP damages the corneal endothelial pump, leading to chronic corneal edema. This results in the formation of epithelial vesicles and bullae (bullous keratopathy), which can rupture and cause further pain. * **C. Atrophic iris:** Long-standing high pressure causes ischemia of the iris tissue, leading to iris atrophy, a fixed dilated pupil, and sometimes ectropion uveae. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** The eye is "stony hard" on digital palpation. * **Optic Disc:** Shows total **glaucomatous cupping** (Cup-Disc Ratio of 1.0). * **Management Goal:** The focus is on **pain relief**, not vision restoration. Modalities include cyclodestructive procedures (e.g., Diode Laser Cyclophotocoagulation), retrobulbar alcohol injections, or enucleation if pain is intractable. * **Distinction:** Absolute Glaucoma = High IOP; Phthisis Bulbi = Low IOP.

Practice by Chapter

Aqueous Humor Dynamics

Practice Questions

Primary Open-Angle Glaucoma

Practice Questions

Primary Angle-Closure Glaucoma

Practice Questions

Secondary Open-Angle Glaucomas

Practice Questions

Secondary Angle-Closure Glaucomas

Practice Questions

Developmental and Congenital Glaucomas

Practice Questions

Medical Management of Glaucoma

Practice Questions

Laser Therapy in Glaucoma

Practice Questions

Glaucoma Filtration Surgery

Practice Questions

Glaucoma Drainage Devices

Practice Questions

Angle Assessment Techniques

Practice Questions

Visual Field Testing in Glaucoma

Practice Questions

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Glaucoma — MCQs

Glaucoma — MCQs

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